Asthma (Reactive Airway Disease)

Dr. Alaa Abdullah Nassar

Pediatrician and neonatologist
Arab Board and Palestinian Board
Dura Governmental Hospital
Hadassah Hospital, Ein Kerem, Preterm Unit NICU
Head of the Pediatric Department, H-Clinic Ramallah
Hospital previously
 Definitions
 Epidemiology
 Etiology
 Pathophysiology
 Clinical feature
 Ddx
 Dx
 Management
 Status asthmaticus
 

Asthma:
Is a chronic inflammatory disorder of the airways , resulting in
widespread and variable airflow obstruction due to airway hyper
responsiveness to many stimuli ( trigger)

Wheezing :
Musical and continuous sound originates from oscillations in narrowed
airways, heard on expiration .

Monophonic or polyphonic

Obstruction occurs in extra thoracic airways during inspiration, the

noise called stridor .
Asthma is the most common chronic pediatric
disease.

Between 50 and 80% of children who have asthma develop

symptoms by 5 years .

Higher prevalence in African American , low

socioeconomic populations , rural area
Pathophysiology

Airway hyper responsiveness lead to inflammation and

obstruction of airways
Increased production and infiltration of inflammatory cells
( eosinophils ) with release of inflammatory mediators (cytokins )

Smooth muscle bronchoconstriction

Airway mucosal edema
Increased mucous secretions
Airway wall remodeling.
There are 2 types of childhood asthma

Recurrent wheezing in early childhood, primarily

triggered URTI , resolve by 6 years.

Chronic (persistent ) asthma persists into later childhood

and\or adulthood .
The child has increased risk to developed asthma if he has a
positive asthma predictive index.

A positive asthma predictive index is either

1. One of the following: atopic dermatitis, parental asthma,
sensitization to allergens
2. Two of the following: wheezing apart from colds,
sensitization to foods, ≥4% Eosinophils on CBC
 
Etiology:
Unknown , multi factorial inheritance

-Host factors: genetics , atopy , family history of asthma

-Environmental factors : tobacco smoke, URTI , diet, and

pollution
 
Triggers of exacerbations: respiratory infections, exercise,
cold air, emotions, allergens, gastro esophageal reflux, and
exposure to pollutants.
Seasonal aeroallergen (trees , grasses)
 
Co-morbid conditions : lung diseases, such as cystic fibrosis,
PCD,CHD , GERD , sinusitis , rhinitis (indirect triger)
Clinical features

Hx : dry cough , chronic or recurrent cough (especially at

night) , DOB , chest pain .

During an exacerbation: signs of RDS ( tachypnea, dyspnea,

nasal flaring, retractions) .

Examination : expiratory wheezing with a prolonged expiratory

phase. Decrease air entry , Crackles due to secretion
 
Silent chest in case of sever airflow obstruction ( tachypnea ,
sever decrease AE , whizzes may not be present )

Signs of atopy or eczema

“All that wheezes is not asthma.”

Differential diagnosis of acute wheezing

Differential diagnosis of recurrent or chronic wheezing
Diagnosis

A. Clinical and therapeutic response to a bronchodilator trial.

B. CXR often reveals hyperinflation, peribronchial thickening, and

patchy atelectasis.

C. PFTs reveal increased lung volumes and decreased expiratory flow

rates.
Spirometry measure FEV1 FVC , done in a child > 5 years of age ,
showed airflow obstruction,
FEV1 >80% NL , 60-80% mod airflow obstruction , <60 % sever
obstruction .

D. Allergy prick skin test : asses sensitization to inhalant allergen

 
Management: based on

Asthma severity intermittent , persistent ( mild,

moderate, or severe)
Asthma control : well, not well, or very poorly controlled
 
There are 4 keys for asthma management :
A. Asthma chick up
B. Patient education
C. Control environmental factors
D. Medications.
 
A : Assessment and monitoring and chick up
Follow-up every 2-4 wk until good control , then 2-4/yr to
maintain good control
Administration technique, and patient adherence
 
B:Patient education
include a written material about daily medications (e.G. Doses, SE,
how to use inhalers) & the action plan for asthma exacerbations
 
 
C : Control of factors contributing to asthma severity
Eliminate allergens, pollutants, irritants ,
 treat comorbid conditions (e.g., allergic rhinitis , gastroesophageal
reflux, obesity, stress).
annual influenza vaccination
aspirin-induced asthma and other NSAID → exacerbations of disease.
rare in children

D : Asthma pharmacotherapy; long-term-control & quick-relief

medications with step-up & step-down approach according to asthma
severity.
 
 Long-Term Controller Medications
) ICS , LABA, LTRA , THEOPHYLLIN ,ANTI IgE )

ICS:
Beclomethasone , Fluticasone, Mometasone, & Budesonide.
delivered by 4 methods:
MDI for older children.
Spacer inhaler for younger children .
DPI (Dry Powder Inhaler).
Nebulizer.

After ICS, mouth wash .

 
LABA:
Salmeterol, formoterol , duration of action ≈12 hr, (usually
in combination with ICS ).
 
Theophylline :
Aminophylline , bronchodilator with anti inflammatory , no
longer considered as first line ? drug interactions, frequent
dose monitoring ,SE ; headache, vomiting, seizures, cardiac
arrhythmias, death!.
 

Leukotriene-modifying agents:
Montelukast , zafirlukast (≥5 yr) & zileuton (≥12 yr).
Broncho - dilator & anti-inflammatory properties
Mast cell stabilizer

Anti-IgE (omalizumab):
It is a antibody binds IgE to prevent its binding to the IgE
receptor, blocking the IgE-mediated allergic responses and
inflammation.
Used >12 years with moderate to severe asthma .May cause
severe anaphylaxis.
 
Quick-reliever (rescue) medications

Short-acting inhaled β-agonists (SABA) :

Albuterol, terbutaline . they have a rapid onset of action that
last for 4–6 hr.
Systemic corticosteroids :
prednisolone, or methylprednisolone for severe asthma
exacerbations .need monitoring for SE , tapering of
medication .
Inhaled anticholinergic:
Ipratropium bromide used in combination with SABA in
acute and severe asthma , bronchodilator & ↓ mucus
production .
classification of asthma severity is depends on the most severe symptoms before Rx.

**FEV1 or peak flow Normal between Exacerbation (>80%) >80% 60–80% <60%
Stepwise approach in asthma management:-
 
Step 1: mild intermittent asthma
Symp ≤2 day/wk or ≤2 night/mo.
Rx. rescue medications SABA only without daily controller
rx.
 
 Step 2: mild persistent asthma
Symp >2 day/wk or >2 night /mo.
Rx. Daily controller therapy by only one of following: low-
dose ICS, leukotrine modifiers .
 
Step 3: Moderate Persistent Asthma
Symptoms daily or >1 night /wk.
Rx. Low-dose ICS + LABA (or Leukotrine modifiers) , or
Medium-dose ICS +/_ (LABA or Leukotrine modifiers).
 
Step 4: Severe Persistent Asthma
continuous daily symp or frequent night symp.
Rx. High-dose ICS + LABA +/_ Systemic corticosteroids.
· Quick-Reliever (Rescue) Medications can be used at any step
when there are severe asthma exacerbations by: SABA +/_
Systemic corticosteroids (IV or orally).

· Before step-up therapy, review patient medication technique,

adherence, and environmental control.

· Step-down medications when there is a good control of

asthma for at Least 3 Months by ↓ the dose or frequency of
medications.

Exercise -induced bronchospasm, pretreatment with SABA

or LTRA , warm-up period.
 Severe asthma exacerbation
(status asthmaticus)
 
Risk factors :

Previous attacks, Hx of rapidly occurring attacks , poor

asthma control
Allergen exposure, tobacco smoke or air pollution
Economic & Psychosocial e.g. Poverty, Crowding, Young or
uneducated mother , inaccessible medical care .  
Clinically

-Sever RD ( dyspnea, tachypnea, retractions, use of accessory

muscles, cyanosis ) , mental status changes, tripod sitting
with inability to talk
-Exam : silent chest , tachycardia (or bradycardia due to
hypoxia). Dehydration
-FEV1 in SAE usually < 50% , oximeter showed hypoxia <90%
Investigation

CXR : atelectasis , air leak , hyperinflation-

Cbc , s lytes ? abnormal-
ABGS :initially Resp alkalosis (hyperventilation ) then resp-
acidosis (hypoventilation )and metabolic acidosis

**NL PCO2 at presentation is ominous sign of pending resp

failure
Treatment :
 ICU with continuous cardiorespiratory monitoring
 Oxygen , O2 saturation >94% .
 Inhaled SABA (can be repeated every 20 min).
 Systemic corticosteroids
 Inhaled Ipratropium bromide
 Adrenalin SC or IM (0.01 mg/kg).
 Terbutaline infusion (with cardiorespiratory monitoring).
 Other medications e.g. Aminophylline infusion, MgSO4.
 Mechanical ventilation for extreme cases with impending
respiratory failure

 Pt can be discharge when he is clinically not distressed sat > 94% ,

with his medication , SABA , short course oral corticosteroid .
 Review of his medication .